loading...
NANDA Definition: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or the sleep/wake cycle
Defining Characteristics: Lack of motivation to initiate and/or follow through with goal-directed or purposeful behavior; fluctuation in psychomotor activity; misperceptions; fluctuation in cognition; increased agitation or restlessness; fluctuation in level of consciousness; fluctuation in sleep-wake cycle; hallucinations
Related Factors: 60 years of age; dementia; alcohol abuse; abuse; delirium; uncontrolled pain; multiple morbidities and medications
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Distorted Thought Control
• Information Processing
• Memory
• Neurological Status: Consciousness
• Safety Behavior: Personal
• Sleep
Client Outcomes
• Cognitive status restored to baseline
• Obtains adequate amount of sleep
• Demonstrates appropriate motor behavior
• Maintains functional capacity
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Delusion Management
Nursing Interventions and Rationales
• Assess client’s behavior and cognition systematically and continually throughout the day and night as appropriate. Rapid onset and fluctuating course are hallmarks of delirium. The Confusion Assessment Method is sensitive, specific, reliable, and easy to use.. Nurses play a vital role in assessing acute confusion because they provide 24- hours-a-day care and see the client in a variety of circumstances. Delirium always involves acute change in mental status; therefore knowledge of the client’s baseline mental status is key in assessing delirium.
• Perform an accurate mental status exam that includes the following:
o Overall appearance, manner, and attitude
o Behavior observations and level of psychomotor behavior
o Mood and affect (presence of suicidal or homicidal ideation as observed by others and reported by client)
o Insight and judgment
o Cognition as evidenced by level of consciousness, orientation (to time, place, and person), thought process and content (perceptual disturbances such as illusions and hallucinations, paranoia, delusions, abstract thinking)
o Attention
Abnormal attention is an important diagnostic feature of delirium. Delirium is a state of mind, while agitation is a behavioral manifestation. Some clients may be delirious without agitation and may actually have withdrawn behavior. This is a hypoactive form of delirium. Some clients have a mixed hypoactive/hyperactive type of delirium .
• Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, medications with known cognitive and psychotropic side effects). Such alterations may be contributing to confusion and must be corrected. Medications are considered the most common cause of delirium in the ICU.
• Treat underlying causes of delirium in collaboration with the health care team: Establish/maintain normal fluid and electrolyte balance; establish/maintain normal nutrition, body temperature, oxygenation (if patients experience low oxygen saturation treat with supplemental oxygen), blood glucose levels, blood pressure.
• Communicate client status, cognition, and behavioral manifestations to all necessary providers. Monitor for any trending of these. Recognize that client’s fluctuating cognition and behavior is a hallmark for delirium and is not to be construed as client preference for caregivers. Careful monitoring may allow for various symptoms to be related to various causes and interventions.
• Lab results should be closely monitored and physiological support provided as appropriate. Once acute confusion has been identified, it is vital to recognize and treat the associated underlying causes .
• Establish or maintain elimination patterns. Disruption of elimination may be a cause for confusion. Changes in elimination patterns may also be a symptom of acute confusion. Prompt response to requests for assistance with elimination in addition to timed voids may assist in maintaining regular elimination, orientation, and patient safety.
• Plan care that allows for appropriate sleep-wake cycle. Disruptions in usual sleep and activity patterns should be minimized as those clients with nocturnal exacerbations endure more complications from delirium.
• Review medication. Medication is one of the most important modifiable factors that can cause delirium, especially use of anticholinergics, antipsychotics, and hypnosedatives .
• Decrease caffeine intake. Decreasing caffeine intake helps to reduce agitation and restlessness .
• Modulate sensory exposure and establish a calm environment. Extraneous lights and noise can give rise to agitation, especially if misperceived. Sensory overload or sensory deprivation can result in increased confusion. Clients with a hyperactive form of delirium often have increased irritability and startle responses and may be acutely sensitive to light and sound.
• Manipulate the environment to make it as familiar to the patient as possible. Use a large clock and calendar. Encourage visits by family and friends. Place familiar objects in sight. An environment that is familiar provides orienting clues, maintains an appropriate balance of sensory stimulation, and secures safety .
• Identify self by name at each contact; call patient by his or her preferred name. Appropriate communication techniques for clients at risk for confusion .
• Use orientation techniques. However, if client becomes distressed or argumentative about what is real, do not argue with the client. Rather, explore the emotion behind the client’s non–reality-based statements.
• Offer reassurance to the client and use therapeutic communication at frequent intervals. Client reassurance and communication are nursing skills that promote trust and orientation and reduce anxiety .
• Provide supportive nursing care. Delirious patients are unable to care for themselves as a result of their confusion. Their care and safety needs must be anticipated by the nurse.
• Identify, evaluate, and treat pain quickly (see care plan for Acute Pain). Untreated pain is a potential cause for delirium.
Geriatric
• Mobilize client as soon as possible; provide active and passive range of motion. Older clients who had a low level of physical activity before injury are at a particular risk for acute confusion .
• Provide sufficient medication to relieve pain. Older clients may give inaccurate pain histories; underreport symptoms; not want to bother the nurse; and exhibit restlessness, agitation, or increased confusion .
• Because anxiety and sensory impairment decrease the older client's ability to integrate new information, explain hospital routines and procedures slowly and in simple terms, repeating information as necessary .
• Provide continuity of care when possible (e.g., provide the same caregivers, avoid room changes). Continuity of care helps decrease the disorienting effects of hospitalization (Matthiesen et al, 1994).
• If clients know that they are not thinking clearly, acknowledge the concern. Confusion is very frightening .
• Do not use the intercom to answer a call light. The intercom may be frightening to an older confused client .
• Keep client's sleep-wake cycle as normal as possible (e.g., avoid letting client take daytime naps, avoid waking clients at night, give sedatives but not diuretics at bedtime, provide pain relief and backrubs). Acute confusion is accompanied by disruption of the sleep-wake cycle.
• Maintain normal sleep/wake patterns (treat with bright light for 2 hours in the early evening). This facilitates normal sleep/wake patterns .
Home Care Interventions
• Monitor for acute changes in cognition and behavior. An acute change in cognition and behavior is the classic presentation of delirium. It should be considered a medical emergency.
Client/Family Teaching
• Teach family to recognize signs of early confusion and seek medical help. Early intervention prevents long-term complications.
http://nursing-concept.blogspot.com
